Palonosetron (Aloxi®) is a serotonin-3 (5-HT3) receptor antagonist used as an antiemetic and antinauseant agent used for the treatment and prevention of post-operative nausea and vomiting as well as nausea and vomiting caused by cancer chemotherapy, radiotherapy, and pregnancy.
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Food and Drug Administration (FDA) Indications
Palonosetron (Aloxi) may be considered medically necessary in individuals 18 years of age and older when ANY of the following criteria are met:
Palonosetron (Aloxi) may be considered medically necessary for pediatric individuals 1 month of age to less than 17 years for:
National Comprehensive Cancer Network (NCCN) Approved Recommendations
Palonosetron (Aloxi) may be considered medically necessary when used in combination with dexamethasone before intravenous antineoplastic therapy with:
Note: May use with or without lorazepam, histamine-2 blockers, or proton pump inhibitors.
Palonosetron (Aloxi) injection performed for indications other than those listed above will be denied as not medically necessary.
Note: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.